Subacute Within a Rehab Hospital
Filling the Patient Care Gap
By Christine McLaughlin
Ask three people to define the term "subacute care" and you'll get three different answers. Why? Mostly because the term still hasn't been officially defined by the federal government, thus it lacks universality in the health care community.
But the underlying idea from the various definitions will be that a subacute care facility is the health care setting where patients who are too sick to be discharged go following acute care; and that it's a more cost-effective way of providing health care because patients are not as ill as they are in an acute setting so less intense, less costly treatment is used.
Despite the ambiguities of it, subacute programs are one of the fastest growing areas of health care delivery today and are found in virtually every setting--rehab hospitals are no exception. In fact, throughout the United States some rehab hospitals have established their own subacute units to fill the gap from acute care to acute rehab.
"[Acute care] hospitals are currently working hard to get people out in a shorter time period, so some patients go straight into a rehab hospital [without a subacute unit] when they're not quite ready," said Jean Hardy, RN, NHA, who is the administrator of the subacute program at Bryn Mawr Rehab Hospital in Malvern, PA. She explained that subacute programs help ease patients into the appropriate subsequent setting.
"In our subacute unit, we provide the care for that interim period to help these patients gain some strength and, hopefully, work their way into an acute rehabilitation program."
Hardy clarified that Bryn Mawr's Transitions Center is a 23-bed subacute unit within the hospital, but considered a separate entity for billing purposes. Licensed and recognized by Medicare (the primary payer) as a skilled nursing facility, the TC, documents and bills with long-term care regulations and guidelines in mind. This designation allows for the lower intensity therapies to be reimbursed, according to Hardy. For example, in the acute rehab setting, patients are expected by general Medicare rules to receive at least three hours of therapies a day, which are reimbursed accordingly--most patients who are candidates for subacute care cannot tolerate that much therapy.
"THE PRIMARY advantage of having SNF status is it allows us to give patients rehab at a much slower and less intense pace than they would receive in acute rehab because most of the patients are aged 65 or older and cannot take the fast pace of acute rehab," noted Hardy. With an average length of stay of 16 to 18 days, and therapies that last anywhere from one to two hours, the TC gives the patients additional time they need to progress.
"We get the same functional results [as those in acute rehab], but it just takes our patients a little longer to get there," Hardy stressed. Additionally, she mentioned that she and her colleagues have observed that patients who are first in the subacute program and then transferred to acute rehab, generally progress further in acute rehab in a shorter period of time than those patients of similar diagnoses who were only admitted to acute rehab.
Many of the admissions to the TC come from local acute-care hospitals, however. Bryn Mawr Rehab utilizes clinical liaisons who are responsible for visiting the acute-care hospitals to review patient charts, discuss the status of the patient with patients and their families, and make the recommendation to the physician whether their next level of care should be the TC or the acute rehab unit at Bryn Mawr Rehab.
Even though subacute units within rehab hospitals must meet the same documentation and licensing requirements, they all do not serve the same populations of patients. One physical therapist at Bryn Mawr Rehab, Amanda Starr, noted that she once worked for a subacute unit at another rehab hospital that consisted primarily of patients with orthopedic problems, and at a freestanding subacute unit that consisted primarily of patients who were ventilator dependent; whereas the TC treats patients with a variety of medical conditions; these include neurological, general medical/surgical, respiratory, orthopedic and wound care.
ONE OF the biggest advantages of having a subacute unit housed within the rehab hospital is that the same therapists who treat in acute rehab also treat in the TC, which provides for more consistency. And the close proximity of the subacute unit to the acute unit allows for more effective communication between therapists about the patient. "We discuss patients as a team and are in touch with each other on a daily basis. In an off-site subacute unit, that type of communication with the rehab hospital just isn't possible," emphasized Starr, stroke team coordinator at the hospital.
What's more, the fact that the subacute unit is in-house allows for flexibility to bring patients from TC to acute rehab soon after the therapists and physicians make the determination that they're ready, rather than waiting through a bureaucratic process to get patients transferred. And if a patient is still not tolerant of the therapies in acute rehab, then he can be transferred back to the subacute unit.
"All the therapists know each other in all areas of the hospital, so when a patient goes [to the TC] or to the acute rehab, the therapists can discuss what exactly the patient needs to finish off their stay," said Starr, who sends her acute rehab patients with stroke to the subacute unit if they cannot tolerate the therapies. "From a cost containment standpoint, it's effective because the patient gets a customized treatment plan that meets his needs and that isn't focused on the number of hours therapy is provided."
While Starr does not work directly in the TC, she helped establish the program in October 1995 because of her prior experience working in subacute units. She worked in the TC for the first few months helping educate the staff on the different rules and regulations with Medicare. At first, she said, there was some resistance from the PTs because it requires a different level of paperwork. But they soon realized how valuable the background was. "The way things look today, with subacute facilities popping up all over the place, most every therapist will deal with this type of paperwork at some point." Also, having the subacute paperwork and documentation background will enable the therapists to work at a hospital-affiliated nursing home if the need arises.
Moreover, since the subacute unit opened and therapists had to learn to recognize which patients are candidates for subacute or acute rehab, it has facilitated the streamlining of patient care throughout the hospital, according to Starr. This complements Byrn Mawr Rehab's patient-centered care philosophy.
Because even Medicare will become "managed" and more health care dollars will need to be saved, the likelihood that subacute units will grow in number and in popularity is good. Subacute care might even take over some of the acute rehab market, both Starr and Hardy said. "We provide a lot of the care that has traditionally been done in some of the acute rehab hospitals. Payers are not looking to put people in acute settings for some diagnoses because it's just too expensive. So I think [subacute programs] will continue to capture those patients," concluded Hardy.